<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('User_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-user_id" data-rule="required" data-source="user/user/index" data-field="nickname" class="form-control selectpage" name="row[user_id]" type="text" value="{$row.user_id|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Check_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-check_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[check_time]" type="text" value="{:$row.check_time?datetime($row.check_time):''}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Check_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-check_date" class="form-control datetimepicker" data-date-format="YYYY-MM-DD" data-use-current="true" name="row[check_date]" type="text" value="{$row.check_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Check_dev_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-check_dev_no" class="form-control" name="row[check_dev_no]" type="text" value="{$row.check_dev_no|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Vender_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-vender_id" data-rule="required" data-source="vender/index" class="form-control selectpage" name="row[vender_id]" type="text" value="{$row.vender_id|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Exam_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-exam_no" class="form-control" name="row[exam_no]" type="text" value="{$row.exam_no|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ecg_result')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ecg_result" class="form-control" name="row[ecg_result]" type="text" value="{$row.ecg_result|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ecg_img')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ecg_img" class="form-control" name="row[ecg_img]" type="text" value="{$row.ecg_img|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ecg12_img')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ecg12_img" class="form-control" name="row[ecg12_img]" type="text" value="{$row.ecg12_img|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('User_mode')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-user_mode" class="form-control" name="row[user_mode]" type="number" value="{$row.user_mode|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
